急性重症后循环梗死患者机械取栓术后临床观察

Clinical effect of mechanical thrombectomy in patients with acute severe posterior circulation infarction

目的 观察急性重症后循环梗死(ASPCI)患者机械取栓术后的疗效,并明确ASPCI的病因机制及预后相关因素。方法 秦皇岛市第一医院2020年1月至2023年6月收治的经全脑血管造影证实为急性后循环大血管闭塞行机械取栓(NIHSS评分≥15分)的患者58例。年龄38~88 (63.0±10.5)岁,诊断均符合2018年中国急性缺血性脑卒中(AIS)诊治指南标准。依据术后90 d MRS评分情况,分为预后良好组(MRS 0~3分)24例和预后不良组(MRS>3分)34例。观察两组ASPCI患者机械取栓术后的疗效,并进一步探索ASPCI患者的病因机制及预后的相关影响因素。结果(1)本组患者的血管开通率为89.7%,无效再通率46.2%,症状性颅内出血率6.9%,术后3个月内血管再闭塞发生率5.2%,预后良好占比41.4%,死亡率37.9%;(2)进行缺血性卒中病因学分型,大动脉粥样硬化型为主要病因分型,占比72.4%。对两组患者行病因分型比较,显示差异无统计学意义(P> 0.05);(3)进一步对组患者常见危险因素、临床特征及手术相关资料进行比较,发现年龄、性别、吸烟、饮酒、高血压、糖尿病、心房颤动、高尿血症、高同型半胱氨酸血症等危险因素及基础NIHSS评分、静脉溶栓占比等在两组所占比例差异均无统计学意义(P>0.05);但发病至再通时间两组比较差异有统计学意义,预后良好组明显短于预后不良组(P=0.017)。结论 ASPCI患者发病时症状重、昏迷程度深,死亡率高,经过积极的血管内治疗可挽救部分患者生命及改善预后。急性重症PCI的患者多以大动脉粥样硬化型为主要病因分型,动脉粥样硬化病变基础上的原位血栓形成是导致ASPCI的主要原因,具有大动脉粥样硬化型病变的患者,机械取栓术后发生再闭塞的风险可能会增加。进一步对两组患者常见危险因素、临床特征及手术相关资料进行比较,发现发病至再通时间比较,差异有统计学意义,预后良好组明显短于预后不良组。尽早恢复血管再通是挽救缺血半暗带脑组织及影响临床预后的关键。

Objective lo observe the efficacy of mechanical thrombectomy in patients with acute severe posterior circulation infarction(ASPCI),and to further identify the main etiological mechanism and prognostic related factors in ASPCI patients.Methods A total of 58 ASPCI patients admitted to our hospital from January 2020 to June 2023 were selected,whose ages ranged from 38 to 88(63.0±10.5)years.All patients were diagnosed based on the criteria of the Chinese Guidelines for diagnosis and treatment of acute ischemic stroke 2018.The patients were divided into good prognosis group(MRS 0-3,n=24)and poor prognosis group(MRS>3,n=34),basing on the MRS scores 90 days after operation.To observe the efficacy of mechanical thrombectomy in ASPCI patients,and to further identify the main etiological mechanism and prognostic related risk factors in ASPCI patients.Results ① In this group,the vascular patency rate was 89.7%,the rate of clinically ineffective reperfusion was 46.2%,the rate of symptomatic intracranial hemorrhage was 6.9%,the rate of vascular re-closure within 3 months after surgery was 5.2%,the rate of good prognosis was 41.4%,and the mortality rate was 37.9%;② Major atherosclerosis was the main etiological mechanism,accounting for 72.4%.There was no significant difference compared with the other groups(P>0.05)in etiological subtype between the two groups;③ Comparison of common risk factors,clinical features and surgical data of patients in different prognosis groups showed that:age,sex,smoking,drinking,hypertension,diabetes,atrial fibrillation,hyperuricemia,hyperhomocysteinemia,basic NIHSS score,proportion of intravenous thrombolysis in different prognosis groups had no statistical significance(P>0.05).However,time in good prognosis group from onset to vascular recanalization is significantly shorter than that in poor prognosis group.Conclusion Patients with ASPCI have severe neurological dysfunction,deep coma and high mortality,active endovascular therapy can save the lives of some patients and improve their prognosis.Major atherosclerosis was the main etiological mechanism in ASPCI patients,and in situ thrombosis based on atherosclerotic lesions is the main cause,which may increase the risk of vascular re-closure after mechanical thrombectomy.Comparison of common risk factors,clinical features and surgical data of patients in different prognosis groups showed that:time in good prognosis group from onset to vascular recanalization is significantly shorter than that in poor prognosis group.Early restoration of vascular recanalization is the key to save ischemic penumbra brain tissue and affect clinical prognosis.